Challenges for U.S. Attorneys Offices (USAO) in Opioid Cases

Transcription

1 Challenges for U.S. Attorneys Offices (USAO) in Opioid Cases

2 Overview On August 2, 2017, U.S. Attorney General Jeff Sessions announced a pilot program whereby a new federal data analysis program is being created to identify any prescribers and pharmacies that may be dispensing and/or prescribing a disproportionate number of opioids. To further support the initiative and assure that the data from the new tracking system results in effective prosecutions, Mr. Sessions committed 12 federal prosecutors to the 12 districts where the epidemic is at its worst. Every U.S. Attorney was charged to designate an Opioid Coordinator by December 15, Essential Keys Finding Help About Qlarant Standards in the Industry Competitive Advantages Necessary Analytics Next Steps Good Data Analysis: An Essential Key to Success The key to identifying issues with opioids is understanding the vulnerabilities that have created pathways to abuse and overutilization. Data analysis, when interpreted correctly, can reveal those risk factors. This necessitates using sophisticated targeted algorithms and an automated tool to mine data sources for connections, patterns, outliers, and trends that contribute to the likelihood of increased use and misuse of opioids. U.S. Attorney Offices (USAOs) need advanced analytics solutions that are specifically designed for the opioid abuse problems facing many states. It is important to stress that the key to any solution is to include rigorous data analytics that continually refine algorithms for statistical significance. Below are some data sources for consideration. Insurer claims (Medicaid if this is the only data available) Hospital data Law enforcement intake records Prescription Drug Monitoring data (if available) Incarceration data State Managed Care data 2

3 Where Can I Get the Data Analysis Help I Need? Qlarant (formerly Health Integrity) has been the only contractor providing surveillance and detection of prescription drug abuse to the Centers for Medicare & Medicaid Services (CMS) nationally since This contract primarily involves data analysis and investigation into wasteful and fraudulent drug payments, including the misuse and unsafe use of controlled substances, focusing on opioids in particular. With the subject-matter knowledge of our expert pharmacists, data analysts, and investigators, Qlarant staff develops key risk indicators and algorithms to be applied to data files, looking for patterns and questionable behaviour and interactions. These data files can be prescription-drug claim or monitoring data, law-enforcement intake records, medical record databases, and other data sets that may be either publicly known or only available to state agencies or law enforcement responsible for public health and safety. About Qlarant Qlarant, a 503(c) company, employs over 500 highly skilled associates with extensive experience in human services and health care. We focus on a variety of healthcare topics including data analytics, risk scoring, and fraud, waste, and abuse (FWA) detection and pursuit through our partnership with federal and state enforcement entities. Qlarant s partners include the Health and Human Services Office of Inspector General (HHS/OIG), the Federal Bureau of Investigation (FBI), and the Drug Enforcement Administration (DEA). Qlarant has hired and retained staff members whose skill sets together drive and transform business problems into business solutions. This is possible through the unique collaboration of professionals with specialized skill sets, such as credentialed data scientists and subject matter experts, across the healthcare business area. Our talented staff includes auditors, compliance experts, former law enforcement and state Medicaid officials, physicians, policy experts, senior nurses, as well as investigators, pharmacists, epidemiologists, and data scientists. We provide excellent consulting services to assist the USAOs and other collaborative law enforcement bodies in utilizing the data findings and providing the tools and support for successful prosecutions. Qlarant s clinical pharmacy experts bring a wide range of experience in dealing with the opioid epidemic. Our pharmacists have several decades of experience in both traditional and nontraditional pharmacy practice settings (e.g., community/retail pharmacies, hospitals, long-term care facilities, correctional institutions, prescription drug plans, pharmaceutical industry) in addition to their current work ferreting out FWA schemes for CMS. Our Qlarant pharmacists are experienced in the direct care of individuals suffering from opioid addiction. They have also developed policies and procedures for health plans and government agencies to use in combatting 3

4 the crisis and providing unique and varied approaches in dealing with this issue. As part of our government work, Qlarant has developed multiple data analysis projects and predictive analytic tools to aid in the detection of opioid misuse and abuse. These projects have focused on enhancing education, awareness, and oversight at all levels of the drug distribution chain. What Are Other USAO Offices Doing? There are 94 USAO offices throughout the country as demonstrated by this link listing current USAOs: Addressing the Heroin and Opioid Crisis, a lengthy, 91-page bulletin published in September 2016, provides some insight into the initiatives on the national crisis and the specific activities undertaken in the respective USAO regions ( There is a variety of regional task forces established to identify and pursue addiction issues. Each task force has its own structure and mission statement. The USAO offices participate as an active member of the task forces and undertake collaborative law enforcement efforts with the States Attorneys General offices, legislative task forces, DEA, and often the FBI. State government agencies that regulate healthcare providers and entities or provide benefits to our most vulnerable citizens are also included in these efforts. Understanding the specific goals of each region and the unique issues they face is crucial to succeeding. What Differentiates Qlarant from Other Data Analysis Vendors? Qlarant is unique among other data analysis vendors Qlarant s algorithms are developed in collaboration with law enforcement to take advantage of their decades of experience. Qlarant s robust data analysis plans and statistical modeling work goes through rigorous supervisory approval to ensure only outcomes that are statistically significant are pursued. Qlarant uses client data sources coupled with third-party data sources to ensure a complete data inventory. In our Medicare, Medicaid and state work we use claims, encounters, pharmacy invoices, beneficiary and provider enrollment files, state licensing-board information, property records, Google maps, ownership/asset and financial filings, court records, and other custom data available from or on behalf of the client. Qlarant is an industry leader in conducting predictive modeling and analytics. Currently we are the CMS contractor responsible for the National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) program. The purpose of NBI MEDIC is to detect and prevent FWA in the Part C (Medicare Advantage) and Part D (Prescription Drug Coverage) programs on a national level. This provides Qlarant with substantial experience on a 4

5 national level at reviewing key metrics to identify outliers for prosecution and enforcement initiatives. Qlarant has experts in the field who are experienced at collaboration with a variety of federal and state law enforcement entities. Qlarant s expertise in conducting investigations and supporting testimony before the courts is well regarded, as is our ongoing work with these law enforcement entities. While the resources designated as part of the pilot are limited, many USAO offices have already dedicated resources to assist in the fight against opioid abuse specifically and to aid healthcare generally. As new payment methodologies are implemented (including the new value-based models), there will be emerging schemes to investigate. Qlarant is committed to remaining knowledgeable about regulations and the best practices for fighting the opioid epidemic. What Types of Analytics and Data Does Qlarant Believe Are Necessary? Additional important data sources available to utilize for USAO with the traditional sources already mentioned above include: State Prescription Drug Monitoring Program (PDMP) As states are continuing to improve the requirements and monitoring, this data captures all scheduled drugs in specific regions with certain mandatory reporting and includes cash payments. Drug Enforcement Administration (DEA) Receiving data on orders and fulfillment to distributors also assists in identifying outliers to determine if proper protocol is being followed for both manufacturers and distribution. All Payer Claims Databases This information captures more global information that could provide insight to the progression of opioid abuses and how/why they occur. The preceding data can also be utilized to identify entities that are non-compliant with regulations of data reporting, through reconciliation with other available data sources. The result may reveal anomalies that do not logically match the findings from other available source information. Educating the community-at-large about this capability may further deter aberrant participants and stakeholders. Examples of analytical results that can be used as key indicators are: Patients who are prescribed more than 100 morphine milligram equivalents per day Patients who have obtained prescriptions from six or more sources during a given prior period Patients who are currently prescribed more than 40 morphine milligram equivalents of methadone daily Patients who have been prescribed opioids for more than 90 consecutive days 5

6 Patients who are currently prescribed both benzodiazepines and opioids These examples can provide detailed insight into: Current high prescribers Identifying patients (through geo-mapping) who are traveling long distances to obtain narcotics Prescriber behavior-pattern analyses both individually and on a group practice level Additional analytics can be established as data sources are secured and mapped into a standard single database. Through these types of analyses, Qlarant has investigated hundreds of providers for their overprescribing of opioids and has referred those investigations to law enforcement for criminal investigation. Customized Program Options In addition to the preceding core services, Qlarant can create a program around specific needs in each respective region. This gives the USAO great latitude to build upon specific issues known in their area based upon experiences and knowledge of the potential bad actors. Qlarant can also review past prosecutions and the exposed vulnerabilities and recommend potential business process modifications to enhance and negate those vulnerabilities in future prosecutions. Building this type of process improvement can develop solid resolutions and close those gaps for a sound prosecution with visual demonstrative evidence that appeals to jurors and prosecutors who do not fully understand the complexity of healthcare fraud. Next Steps Qlarant would like to schedule a meeting to discuss your specific goals and needs. Initial discussion will assist us in understanding your objectives with regard to analytics, analyses, subject matter expertise, or a plethora of consulting services offered by industry experts. Sandy Love, President Qlarant Integrity Solutions loves@qlarant.com Phone: